2.0 Analysis 2.1 Winter Navigation Whether the winter spar buoys in the area were clearly visible above the waterline could not be established. However, as floating aids can go missing or become displaced, particularly those that have been exposed to winter conditions, their positions cannot be relied upon. Thus pilotage must be conducted primarily using fixed aids and familiar shore-based landmarks. In this instance, as ranges were available to guide the vessel through the Richelieu Rapids and Barre Boulard channels, the status of the floating aids should have had no influence on the outcome of this occurrence. 2.2 Lack of Close Monitoring of the Vessel's Progress During the transit of the Richelieu Rapids, the vessel's course had been adjusted to 225(G) when she was about 0.7 nautical mile (M) from the alter-course position off buoy Q73. This would suggest that either an adjustment of course was essential to maintain the vessel on the recommended track or that the vessel's course was altered to stay close to the west side of the channel. In any event, close monitoring of the vessel's position and progress would have been in order. However, neither the pilot nor the mate effectively monitored the vessel's progress as she navigated through the channel, where a strong current was being experienced. This conclusion is reflected in and consistent with the lack of action by both the pilot and the OOW for some 5 to 10 minutes before bottom contact. 2.2.1 Conflicting Evidence Respecting the Position of Bottom Contact--Impact on Occurrence The pilot maintained that the actual position of bottom contact was further north of the position reported to the VTC. If the position reported to the VTC was accurate, then the vessel would have made good a course of 227(G). The vessel's average speed over the ground between 0647 and the time of bottom contact would have been about 6 kn. As can be seen from Appendix A, the distance between the position of bottom contact and the point at which the vessel would have crossed the next course line is about one mile, and the CANADIAN EXPLORER would have continued past the alter-course position for about 10 minutes before bottom contact was made. On the other hand, had the vessel made good a course of 225(G), her position at the time of bottom contact would have been some 0.75 M in a north-easterly direction from the reported position. This would have given the vessel an average speed over the ground of about 4 kn, and the vessel would then have continued on a course of 225(G) for an additional 6 minutes past the alter-course position before bottom contact was made. Regardless of the course made good, the vessel continued well past the alter-course position for several minutes without action on the part of the pilot or input from the OOW. 2.2.2 Contradictory Evidence Respecting the Current The pilot maintained that the strong current pushed the vessel out of the channel in a matter of seconds; that is, that the vessel drifted some 130 m. For this to occur, the easterly component of the set at right angles to the channel had to have been at a rate greater than 4 kn. However, there is no evidence to suggest that such a cross-current existed in the area. It also was not possible for the current to be three to four times stronger than the usual 5 kn (3 x 5 kn = 15 kn). In any event, the pilot had to have been knowledgeable about the current conditions, and he therefore should have exercised extreme caution and effectively monitored the progress of the vessel. 2.3 Bridge Team Concept The practice of OOWs relying on pilots and rarely questioning a pilot's actions is quite widespread. As pilots are engaged because of their local knowledge and as varying conditions can be experienced, it is essential that the OOW be aware of the pilot's intentions and of the difficulties and constraints of the pilotage area. The OOW is never in a good position to question the pilot regarding the progress of the ship or a situation at any time, unless the OOW knows what should be happening at that time. In this instance, the conduct of the OOW suggests that he was unaware of the pilot's intentions and of the developing situation. The pilot's immediate action after the bottom contact was to look out of the window to determine the vessel's position and then to order the helmsman to steer in the middle of the river. This would indicate that the pilot had lost positional awareness for a time before the vessel touched bottom. The procedures in place on the bridge allowed the pilot and the OOW to operate independently. The opportunity for teamwork to maximize performance was not exploited. A greater degree of interaction between the pilot and the OOW could have resulted in the effective monitoring of the vessel's progress and upgraded performance. It also could have alerted the OOW to potential problems and might have enabled him to initiate preemptive remedial action. 2.4 Pilot Performance The vessel grounded because neither the pilot nor the OOW effectively monitored the vessel's progress through the water. Factors significant to the bottom contact were that, before the occurrence, the pilot was tired and had lost positional awareness, and that the vessel continued past the alter-course position for several minutes. In addition, after the occurrence, the pilot's instructions to the helmsman were to steer in the middle of the channel, where neither buoys were visible and where the only ranges were astern of the vessel. These factors are consistent with the pilot having been asleep at the time of the bottom contact, as was initially indicated to the master. The pilot's performance was degraded by a combination of the work schedules and lack of sleep, and the OOW was not aware that the pilot had fallen asleep. Although the pilot was aware of some of the effects of irregular work schedules, his behaviour pattern and sleep discipline on the period of rest before the occurrence were not conducive to maximizing his performance during the assignment on the night of 15/16 April 1993. This is reflected in the pilot's having been tired despite having been off duty for over 54 consecutive hours between each of his last three assignments. Further, as he had had only about two hours of sleep before this assignment, the pilot was susceptible to inattention to tasks and a lower standard of work, and became vulnerable to falling asleep. 3.0 Conclusions 3.1 Findings There was no interaction between the pilot and the officer of the watch (OOW) regarding the safe navigation of the vessel, nor had any formal procedure been adopted. The practice of OOWs relying on pilots and rarely questioning a pilot's actions is relatively widespread. Neither the pilot nor the OOW effectively monitored the progress of the vessel while transiting an area of strong current under winter navigation conditions. The pilot had had over two days of rest period since his last assignment, but was tired at the start of this assignment. The pilot's behaviour pattern and sleep discipline during rest periods were not conducive to maximizing his performance. The pilot had had the conduct of the vessel for some three and a half hours and was asleep at the time of bottom contact. The CANADIAN EXPLORER overshot the alter-course position and steamed for several minutes before making bottom contact. The Laurentian Pilotage Authority (LPA) has neither directive nor educational programs in place to provide guidance for the pilots on matters relating to work-related stress, fatigue, and performance of people working irregular schedules. 3.2 Causes While transiting the Richelieu Rapids under the conduct of a pilot, the CANADIAN EXPLORER touched bottom because neither the pilot nor the officer of the watch effectively monitored the vessel's progress in an area of strong current. 4.0 Safety Action 4.1 Action Taken 4.1.1 Pilot-Master Relationship Poor communications on the bridge, interrupted procedures, lack of situational awareness, lack of teamwork between pilots and ships' officers, etc. have been contributory factors in several other similar occurrences in recent years. The Board is currently conducting a safety study with respect to the operational relationships between ships' masters, officers of the watch (OOW) and marine pilots. This study is nearing completion and, based on the findings of the study, the Board will make appropriate safety recommendations to improve the effectiveness of bridge team management practices on vessels in Canadian waters. 4.1.2 Employee Assistance Program for Pilots As a result of this occurrence, the Laurentian Pilotage Authority (LPA) and the Corporation des pilotes du Saint-Laurent are exploring the development of an employee assistance program to assist their pilots in safety performance. The LPA reported that it is more vigilant now on the conduct of pilots in general. 4.1.3 Bridge Resource Management (BRM) The Canadian Coast Guard (CCG) has drafted a BRM discussion paper that is presently being reviewed by selected marine schools and pilotage authorities. Once finalized, this paper will form the basis for the development of an optional training course on this subject. In response to this occurrence, both the shipowners and the LPA acknowledged the need for greater interaction between deck officers and pilots. 4.1.4 Study on Fatigue Aboard Canadian Ships A research project by the Transportation Development Centre in Montreal is being completed on the subject of manning and fatigue aboard Canadian ships. This study focuses primarily on hours of work and time of day in order to understand and minimize the effects of fatigue.